Overview
Maternal mortality is unacceptably high. About 287 000 women died during and following pregnancy and childbirth in 2020. Almost 95% of all maternal deaths occurred in low and lower middle-income countries in 2020, and most could have been prevented.
Sustainable Development Goal (SDG) regions and sub-regions are used here. Sub-Saharan Africa and Southern Asia accounted for around 87% (253 000) of the estimated global maternal deaths in 2020. Sub-Saharan Africa alone accounted for around 70% of maternal deaths (202 000), while Southern Asia accounted for around 16% (47 000).
At the same time, between 2000 and 2020, Eastern Europe and Southern Asia achieved the greatest overall reduction in maternal mortality ratio (MMR): a decline of 70% (from an MMR of 38 to 11) and 67% (from an MMR of 408 down to 134), respectively. Despite its very high MMR in 2020, Sub-Saharan Africa also achieved a substantial reduction in MMR of 33% between 2000 and 2020. Four SDG sub-regions roughly halved their MMRs during this period: Eastern Africa, Central Asia, Eastern Asia, and Northern Africa and Western Europe reduced their MMR by around one third. Overall, the maternal mortality ratio (MMR) in least-developed countries* declined by just under 50%. In land locked developing countries the MMR decreased by 50% (from 729 to 368). In small island developing countries the MMR declined by 19% (from 254 to 206).
* For details of countries considered in the group of “least developed” please refer to standard country or area codes for statistical use (M49) available at: https://unstats.un.org/unsd/methodology/m49/.
Where do maternal deaths occur?
The high number of maternal deaths in some areas of the world reflects inequalities in access to quality health services and highlights the gap between rich and poor. The MMR in low-income countries in 2020 was 430 per 100 000 live births versus 12 per 100 000 live births in high income countries.
Humanitarian, conflict, and post-conflict settings hinder progress in reducing the burden of maternal mortality. In 2020, according to the Fragile States Index (1), 9 countries were “very high alert” or “high alert” (from highest to lowest: Yemen, Somalia, South Sudan, the Syrian Arab Republic, the Democratic Republic of the Congo, the Central African Republic, Chad, Sudan and Afghanistan); these countries had MMRs ranging from 30 (the Syrian Arab Republic) to 1223 (South Sudan) in 2020. The average MMR for very high and high alert fragile states in 2020 was 551 per 100 000, over double the world average.
Women in low-income countries have a higher lifetime risk of death of maternal death. A woman’s lifetime risk of maternal death is the probability that a 15-year-old woman will eventually die from a maternal cause. In high income countries, this is 1 in 5300, versus 1 in 49 in low-income countries.
Why do women die?
Women die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy and most are preventable or treatable. Other complications may exist before pregnancy but are worsened during pregnancy, especially if not managed as part of the woman’s care. The major complications that account for nearly 75% of all maternal deaths are (2):
- severe bleeding (mostly bleeding after childbirth);
- infections (usually after childbirth);
- high blood pressure during pregnancy (pre-eclampsia and eclampsia);
- complications from delivery; and
- unsafe abortion.
How can women’s lives be saved?
To avoid maternal deaths, it is vital to prevent unintended pregnancies. All women, including adolescents, need access to contraception, safe abortion services to the full extent of the law, and quality post-abortion care.
Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. All women need access to high quality care in pregnancy, and during and after childbirth. Maternal health and newborn health are closely linked. It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for the women as well as for the newborn.
Severe bleeding after birth can kill a healthy woman within hours if she is unattended. Injecting oxytocics immediately after childbirth effectively reduces the risk of bleeding.
Infection after childbirth can be eliminated if good hygiene is practiced and if early signs of infection are recognized and treated in a timely manner.
Pre-eclampsia should be detected and appropriately managed before the onset of convulsions (eclampsia) and other life-threatening complications. Administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia.
Why do women not get the care they need?
Poor women in remote areas are the least likely to receive adequate health care (3). This is especially true for SDG regions with relatively low numbers of skilled health care providers, such as Sub-Saharan Africa and Southern Asia.
The latest available data suggest that in most high income and upper middle income countries, approximately 99% of all births benefit from the presence of a trained midwife, doctor or nurse. However, only 68% in low income and 78% in lower-middle-income countries are assisted by such skilled health personnel (4).
Factors that prevent women from receiving or seeking care during pregnancy and childbirth are:
- health system failures that translate to (i) poor quality of care, including disrespect, mistreatment and abuse, (ii); insufficient numbers of and inadequately trained health workers, (iii); shortages of essential medical supplies; and (iv) the poor accountability of health systems;.
- social determinants, including income, access to education, race and ethnicity, that put some sub-populations at greater risk;
- harmful gender norms and/or inequalities that result in a low prioritization of the rights of women and girls, including their right to safe, quality and affordable sexual and reproductive health services; and
- external factors contributing to instability and health system fragility, such as climate and humanitarian crises.
To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at both health system and societal levels.
What was the impact of COVID-19 pandemic on maternal mortality?
It is clear from the data that the stagnation in maternal mortality reductions pre-dates the start of the COVID-19 pandemic in 2020. The COVID-19 pandemic may have contributed to the lack of progress but does not represent the full explanation.
The level of maternal mortality during the COVID-19 pandemic may have been impacted by two mechanisms: deaths where the woman died due to the interaction between her pregnant state and COVID-19 (known as an indirect obstetric deaths), or deaths where pregnancy complications were not prevented or managed due to disruption of health services.
A robust global assessment of the impact of COVID-19 on maternal mortality is not possible from the data currently available: only around 20% of the countries and territories have thus far reported empirical data on their maternal mortality levels in 2020, and high-income and/or relatively smaller populations are over-represented in this group – with implications for generalizability of findings.
The current estimates only extend to include the year 2020. Given the limited data, we expect these estimates to be revised in future updates.
The Sustainable Development Goals and maternal mortality
In the context of the Sustainable Development Goals (SDG), countries have united behind the target to accelerate the decline of maternal mortality by 2030. SDG 3 includes an ambitious target: “reducing the global MMR to less than 70 per 100 000 births, with no country having a maternal mortality rate of more than twice the global average”.
The global MMR in 2020 was 223 per 100 000 live births; achieving a global MMR below 70 by the year 2030 will require an annual rate of reduction of 11.6%, a rate that has rarely been achieved at the national level. However, scientific and medical knowledge are available to prevent most maternal deaths. With 10 years of SDGs remaining, now is the time to intensify coordinated efforts, and to mobilize and reinvigorate global, regional, national, and community-level commitments to end preventable maternal mortality.
WHO response
Improving maternal health is one of WHO’s key priorities. WHO works to contribute to the reduction of maternal mortality by increasing research evidence, providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to Member States on developing and implementing effective policy and programmes.
As defined in the Strategies toward ending preventable maternal mortality (EPMM) and Ending preventable maternal mortality: a renewed focus for improving maternal and newborn health and well-being, WHO is working with partners in supporting countries towards:
- addressing inequalities in access to and quality of reproductive, maternal and newborn health care services;
- ensuring universal health coverage for comprehensive reproductive, maternal and newborn health care;
- addressing all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities;
- strengthening health systems to collect high quality data in order to respond to the needs and priorities of women and girls; and
- ensuring accountability in order to improve quality of care and equity.
References
1. Fragile States Index. Available at: https://fragilestatesindex.org/data/.
2. Say L, Chou D, Gemmill A et al. Global Causes of Maternal Death: A WHO Systematic Analysis. Lancet Global Health. 2014;2(6): e323-e333.
3. Samuel O, Zewotir T, North D. Decomposing the urban–rural inequalities in the utilisation of maternal health care services: evidence from 27 selected countries in sub-Saharan Africa. Reprod Health 18, 216 (2021).
4. World Health Organization and United Nations Children’s Fund. WHO/UNICEF joint database on SDG 3.1.2 Skilled Attendance at Birth. Available at: https://unstats.un.org/sdgs/indicators/database/.